Safe handling of parenteral cytotoxics: recommendations for ontario

Evaluation of Robotic Systems on Cytotoxic Drug Preparation: A Systematic Review and Meta-Analysis

Background and Objectives: With the increased prevalence of patients with cancer, the demand for preparing cytotoxic drugs was increased by health-system pharmacists. To reduce the workload and contamination of work areas in pharmacies, compounding robots preparing cytotoxic drugs have been introduced, and the use of the robots has been expanded in recent years. As reports on the comprehensive and quantitative evaluation of compounding robots remain lacking, a systematic review and meta-analysis were conducted to provide descriptive and quantitative evaluations of the accuracy of preparing injectable cytotoxic drugs. Materials and Methods: A systematic review and meta-analysis were conducted using published studies up to 2020. To identify eligible studies, PubMed, EMBASE, and Cochrane Library were used. All studies reporting the outcomes relevant to drug-compounding robots such as accuracy, safety, and drug contamination were included. Outcomes from included studies were descriptively summarized. Drug contamination by the robot was quantitatively analyzed using the odds ratio (OR) with a 95% confidence interval (CI). The risk of bias was assessed using the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS). Results: A total of 14 compounding robot studies were eligible for review and 4 studies were included in the meta-analysis. Robotic compounding showed failure rates of 0.9–16.75%, while the accuracy range was set at 5%. Two studies reported that robotic compounding needed more time than manual compounding, two reported that robotic compounding needed less time, and one just reported preparation time without a control group. In a meta-analysis regarding the contamination of the compounding area, manual compounding was associated with lower contamination, although the result was not statistically significant (OR 4.251, 95% CI 0.439–51.772). For the contamination of infusion bags, the robot was associated with lower contamination (OR 0.176, 95% CI 0.084–0.365). Conclusions: Robotic compounding showed better accuracy than manual compounding and, without control groups, showed a high accuracy rate and also reduced the risk of drug contamination and compounding workload. The preparation time of the robot was not consistent because the type of robot and introduced system were different. In conclusion, robotic compounding showed mixed results compared to the manual compounding of drugs, so the system should be introduced considering the risks and benefits of robots.

Evaluation of the Surface Contamination by Cytotoxic Agents of a Chemotherapy Reconstitution Unit: From Analysing Work Practices to Preventive and Corrective Actions

Introduction:

The staff handling the cytotoxics are exposed to contamination as an occupational hazard. The unit of the Centre Hospitalier Universitaire (C.H.U) of Saint Pierre is ISO9001 certified. In a constant effort to improve the quality of our work, samples of the work surface were collected and allowed us, in a first step, to evaluate the contamination in a CRU in Reunion Island. As a result, corrective and preventive actions were implemented in the work routines.

Material and method:

53 samples of the work surface, collected in December 2015 and in March and April 2016 in seven different spots, were treated in this observational study. The 5-FU was chosen as example and analysed and quantified by using liquid chromatography associated with a mass spectrometer with a detection limit of 2 ng/pf.

Results:

We observed a great difference in contamination; 29 samples were positive, the isolator container was the location with the highest level of contamination, including manipulator gloves under the isolator, work surface and the inside of the isolator bin. The contamination was reduced after a first clean-up with water only.

The overwrapping bags and the manipulator gloves are only a little or not at all contaminated.

Conclusions

In order to reduce the exposure to cytotoxic residuals, corrective actions have been implemented: more frequent changes of manipulator gloves, the use of closed systems, and cleaning of the isolator with water. The efficiency of these modifications of work practices will be evaluated again in a few months.

Using Breakthrough Series Collaborative Methodology to Improve Safe Delivery of Chemotherapy in Ontario

Participation in a collaborative enabled local interdisciplinary teams to develop processes and structures to support ongoing quality improvement, including formation of a sustainable structure for knowledge translation and exchange, but lack of a shared provincial target limited overall evaluation.

Functional differentiation of cytotoxic cancer drugs and targeted cancer therapeutics

There is no nationally or internationally binding definition of the term "cytotoxic drug" although this term is used in a variety of regulations for pharmaceutical development and manufacturing of drugs as well as in regulations for protecting medical personnel from occupational exposure in pharmacy, hospital, and other healthcare settings. The term "cytotoxic drug" is frequently used as a synonym for any and all oncology or antineoplastic drugs. Pharmaceutical companies generate and receive requests for assessments of the potential hazards of drugs regularly - including cytotoxicity. This publication is intended to provide functional definitions that help to differentiate between generically-cytotoxic cancer drugs of significant risk to normal human tissues, and targeted cancer therapeutics that pose much lesser risks. Together with specific assessments, it provides comprehensible guidance on how to assess the relevant properties of cancer drugs, and how targeted therapeutics discriminate between cancer and normal cells. The position of several regulatory agencies in the long-term is clearly to regulate all drugs regardless of classification, according to scientific risk based data. Despite ongoing discussions on how to replace the term "cytotoxic drugs" in current regulations, it is expected that its use will continue for the near future.

Does applying technology throughout the medication use process improve patient safety with antineoplastics?

PURPOSE

Medical errors, in particular medication errors, continue to be a troublesome factor in the delivery of safe and effective patient care. Antineoplastic agents represent a group of medications highly susceptible to medication errors due to their complex regimens and narrow therapeutic indices. As the majority of these medication errors are frequently associated with breakdowns in poorly defined systems, developing technologies and evolving workflows seem to be a logical approach to provide added safeguards against medication errors.

SUMMARY

This article will review both the pros and cons of today's technologies and their ability to simplify the medication use process, reduce medication errors, improve documentation, improve healthcare costs and increase provider efficiency as relates to the use of antineoplastic therapy throughout the medication use process. Several technologies, mainly computerized provider order entry (CPOE), barcode medication administration (BCMA), smart pumps, electronic medication administration record (eMAR), and telepharmacy, have been well described and proven to reduce medication errors, improve adherence to quality metrics, and/or improve healthcare costs in a broad scope of patients. The utilization of these technologies during antineoplastic therapy is weak at best and lacking for most. Specific to the antineoplastic medication use system, the only technology with data to adequately support a claim of reduced medication errors is CPOE. In addition to the benefits these technologies can provide, it is also important to recognize their potential to induce new types of errors and inefficiencies which can negatively impact patient care.

CONCLUSION

The utilization of technology reduces but does not eliminate the potential for error. The evidence base to support technology in preventing medication errors is limited in general but even more deficient in the realm of antineoplastic therapy. Though CPOE has the best evidence to support its use in the antineoplastic population, benefit from many other technologies may have to be inferred based on data from other patient populations. As health systems begin to widely adopt and implement new technologies it is important to critically assess their effectiveness in improving patient safety.

Examining factors that influence the effectiveness of cleaning antineoplastic drugs from drug preparation surfaces: a pilot study

Occupational exposure to antineoplastic drugs has been documented to result in various adverse health effects. Despite the implementation of control measures to minimize exposure, detectable levels of drug residual are still found on hospital work surfaces. Cleaning these surfaces is considered as one means to minimize the exposure potential. However, there are no consistent guiding principles related to cleaning of contaminated surfaces resulting in hospitals to adopt varying practices. As such, this pilot study sought to evaluate current cleaning protocols and identify those factors that were most effective in reducing contamination on drug preparation surfaces. Three cleaning variables were examined: (1) type of cleaning agent (CaviCide®, Phenokil II™, bleach and chlorhexidine), (2) application method of cleaning agent (directly onto surface or indirectly onto a wipe) and (3) use of isopropyl alcohol after cleaning agent application. Known concentrations of antineoplastic drugs (either methotrexate or cyclophosphamide) were placed on a stainless steel swatch and then, systematically, each of the three cleaning variables was tested. Surface wipes were collected and quantified using high-performance liquid chromatography-tandem mass spectrometry to determine the percent residual of drug remaining (with 100% being complete elimination of the drug). No one single cleaning agent proved to be effective in completely eliminating all drug contamination. The method of application had minimal effect on the amount of drug residual. In general, application of isopropyl alcohol after the use of cleaning agent further reduced the level of drug contamination although measureable levels of drug were still found in some cases.

The management of cytotoxic drug wastes in Shiraz, Iran: an overview of all government and private chemotherapy settings, and comparison with national and international guidelines

Excessive use of cytotoxic drugs owing to a dramatic increase in malignancy incidence leads to the production of high amounts of cytotoxic wastes. In Iran, management of hazardous wastes has been neglected in recent decades. The aim of this study was to determine the amount of intravenous cytotoxic drug wastes, their collection and disposal status in chemotherapy wards, and to compare the current status with standard guidelines in Shiraz, Iran. This cross-sectional study was performed using data collected during 2 consecutive months, from 22 June to 22 August 2011, in all 13 chemotherapy wards in Shiraz. The amount of prescribed drugs, drugs waste, collection and disposal status of cytotoxic drugs were recorded. We then compared the current status of waste collection and disposal in our samples with our national guideline. The prescription of cytotoxic drugs and the amount of total drugs waste reached approximately 6 and 0.2 kilograms respectively. Total vials volume was calculated to be approximately 1000 l in order to estimate the volume of containers required for the encapsulation method. The results demonstrated that the current status of cytotoxic waste collection and disposal is inappropriate, and none of the facilities under study followed our guidelines perfectly. The adherence to all recommendations and guidelines was poorer in private wards than in government-run ones. The management of cytotoxic wastes is inappropriate and our existing national guidelines are lacking. Suggestions for the best management of cytotoxic waste are revising the existing guidelines, allocating a sufficient budget, training healthcare workers, providing multiple administration options of cytotoxic drugs and accomplishing a surveillance system.

Evaluation of safe infusion devices for antineoplastic administration

Nurses endure daily low-level exposure to cytotoxic drugs, which can lead to significant absorption with potential harmful consequences. New sterile medical devices called cytotoxic safe infusion systems (CSISs), intended by their manufacturers to improve safety and quality of cytotoxic drug infusions, have been made commercially available. CSISs from 3 manufacturers were tested in 2 cancer units and compared with standard infusion sets. The aim of this study is to evaluate the devices regarding occupational exposure, quality of the infusion, and economic aspects.

The oncology pharmacy in cancer care delivery in a resource-constrained setting in western Kenya

The movement to deliver cancer care in resource-limited settings is gaining momentum, with particular emphasis on the creation of cost-effective, rational algorithms utilizing affordable chemotherapeutics to treat curable disease. The delivery of cancer care in resource-replete settings is a concerted effort by a team of multidisciplinary care providers. The oncology pharmacy, which is now considered integral to cancer care in resourced medical practice, developed over the last several decades in an effort to limit healthcare provider exposure to workplace hazards and to limit risk to patients. In developing cancer care services in resource-constrained settings, creation of oncology pharmacies can help to both mitigate the risks to practitioners and patients, and also limit the costs of cancer care and the environmental impact of chemotherapeutics. This article describes the experience and lessons learned in establishing a chemotherapy pharmacy in western Kenya.